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Y!�ste Tire Survey & Inspection Report Inspection Report mer <br /> .qtrY p p <br /> BCalifornla Survey Form - Page 1 - i - 1 0 1 3 1 4 <br /> CIWMB 181(New 04!04) <br /> California Integrated Waste Management Board <br /> Part_A- Survey_ _ BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPIQ- O � Inspection Type (Fill one) <br /> Site Suffix: y O d 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: s�L ��. a -�Y Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name <br /> -�-� <br /> Inspected By Inspector <br /> Physical Address loll ] <br /> 3 7.75`_ r - <br /> i___ <br /> Street V / ry, <br /> �D Inspection Date t/ <br /> Cty State ZIP Code [1-1 <br /> Time InnTime OutBusiness Rep Title : O PM OPM <br /> Operational StatusTireType Business Role Storage Type <br /> Tire Count(Whole/PTE) { (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f I f ! 0 Active Q Passenger O Generator O Outdoor <br /> Latitude I i I O Closed Q Altered <br /> (Ips L 1 _l J Q Hauler Q Indoor <br /> O Inactive O Truck <br /> Longitude – , <br /> 9 I I . I 0 Planned Q OTR End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> O Service Station Q Hauler 0 Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / [T / M <br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§ 18459 3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> 0 Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • In Compliance - No Violations <br /> Q O Other: § <br /> Comments <br /> l f1es �e�rz 5'r1 epe_I-A A ate, /rte <br /> aze <br /> Inspection Form Included: 0! <br /> Comments Included: ®! <br /> l Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �/ 62081 <br /> INSTRUCTIONS ON BACK Correct:e Incorrect: Ir X A M P LjEj 1112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />